2 DB questions and replies
BabyTazz21
DOC021.pdf
m spectrum disor that_autism.
). Recognition and utism and Develop—
(2004). Comparing lescents and young d without autism. [51—161. iali, S., IVlarcin, C., autism and other
, 5(3), 160—179. D. (2007). Evaluat rh autism spectrum
Autism Spectrum
vi., & Le Couteur, n adolescents with of Child Psychology
y, M., & Lancioni, viduals with devel )evelopmental Dis—
ability: Definition, nt and prognosis.
disability and its in Developmental
of Persons with Mb ties/convention
ectual disability in Velfare, Canberra.
a! skills profiles in Behaviour Moth—
J., & Wray, J. A. )C established from ‘,44(9), 504—510.
Editors’ Note Carolyn Can/iell is a /b;-nier researcher a/ui community organizer v_ho resides in the
Gulf Islands of British Columbia, Canada, Carolyn and her husband Nick Francis, a retired Royal Canadian Air Force chief/lying instructoi; ‘worked/br 20 years as active volunteers in their close—knit island community. The couples lives changed abruptly
when Nick, at the age oJ’79. discovered a lump on the hack ofhis thigh. Doctors identi—
fled it as so_/I tissue sarcoma, a serious and relatively rare cancer that comprises less than 1% 0,/all adult cancers. Standard treatment_/br so/I tis.cue sarcoma in the extremities
is surgical removal, ojlen preceded and/or followed 1’y radiation, chemotherapy, or a combination of the two (Burningham, Flashihe, Spectou; &‘ Schfflnan, 2012j Nick underwent radiation followed by surgical excision of the tumor in a nearby hospital. While recovering in the hospital, he developed delirium and a Clostridium difficile’ infection. Hosp ital stajfwere shocked when he died on his eighth night a_/Icr admission. Carolyn Can_/lAd describes the events o/’ Nick’s ho3pitalization and her quest to imp rove health care by focusing on restoring relationships and trust between patients and provide
CASE 9
A Cascade of Small Events: Learning from an
Unexpected Postsurgical Death
.
The Story of Nick Francis (Canada)
Carolyn Canjield
117
SECTION III:PraciiceBased
Learning and
Im provem
ent CASE
9:A Cascade
ofSmallEvents:Learning from
an Unexpected
PostsurglcalDeath
L E
A R
N IN
G O
B JE
C T
IV E
S
A fter
com pleting
this case
study you
w ill
he able
to:
1. O
utline the
system issues
that w
ere revealcd
in N
ick’s case.
2. D
iscuss the
problem of
fragm entation
in health
care and
w ays
that it
can he
m inim
ized. 3.
C reate
a strategy
to elicit
patient input
in achieving
high— quality
health care.
4. D
iscuss w
ays to
handle recognition
of avoidable
patient harm
and disclosure
of adverse
events in
hospitals.
T he
P erfectP
atien t
In the
spring o f
2008 m
y husband
N ick
had a
biopsy th
at revealed
a m
alignancy in
a lum
p on
the back
o f
his thigh.
N ick
m et
w ith
a surgeon,
and they
agreed th
at surgery
w as
the best
o p tio
n for
reco v
ery. H
e had
preoperative radiation,
and w
e prepared
for the
surgery confident
th at
w e
had a
great team
o f
healthcare practitioners.
W e
had enorm
ous respect
for the
w ay
w e
had been
treated. ‘The surgery
w as
scheduled to
last 3
hours hut
in fact
to o k
7 hours.‘The
surgeon said
it took
a little
longer th
an expected,
h u t
th at
things w
en t
great.
I saw
N ick
w hen
he cam
e o u t
o f
reeoverc H
e w
as groggy,
b u t
said he
w as
happy th
at “the
cu ttin
g part”
w as
over. T
he next
day the
surgeon caine
in and
asked him
to m
ove his
foot around
for m
obility and
for strength.
E v ery
th in
g looked
great.’T he
surgeon w
as delighted
th at
even w
ith rem
oving a
h am
b u rg
er-sized tu
m o
r from
the back
o f
his thigh
and rearranging
som e
m uscles
the prospects
looked good
th at
N ick
w ould
w alk.
N ick
had a
sip o f
b ro
th and
learned how
to use
an incentive
spirom eter
to d
ear his
lungs. It
w as
a really
good day.
‘The next
m o rn
in g
I cam
e back
to the
hospital early,
around 7:00
a.m .
M y
husband w
as w
ild-eyed and
greeted m
e w
ith ,
“T hank
G o d
you’re here.”
H e
then explained
to m
e th
at diarrhea
and nausea
had started
in the
m iddle
o f
the n ig
h t
and he
had n o t
been able
to get
any rest.
lie w
as also
distressed by
vivid im
agery every
tim e
he closed
his eyes:
w hen
his eyes
w ere
open he
w as
the person
I knew
and loved,
but w
h en
he tried
to sleep
delirium b ro
u g h t
on im
ages th
at kept
him aw
ake. H
e w
as frightened
and uncom
fortable and
em barrassed
to need
assistance to
get on
and o ffthe
bedpan so
often. ‘11w
leg surgery
m ean
t staying
im m
obilized in
bed,T he
occupational th
erap ist
had spoken
hopefully about
leg dangling,
learning to
w alk,
and plans
for release
in a
w eek.
N ow
it seem
ed this
w as
going to
be delayed.
It took
3 days
o f
suffering diarrhea
and nausea,
then fever,
before N
ick’s fecal
sam ple
w as
sent to
the lab.
It cam
e back
quickly w
ith a
diagnosis o f
C /ostrja’jum
dfficz/e, an
intestinal infection
th at
is highly
transm issible
in hospitals.
Im m
ediately, I
w as
tau g h t
contact p recau
tions o f
gow ning,
gloving, and
m asking.
N ick’s
TV w
as placed
on a
pole, and
w e
rolled his
bed dow
n to
the end
o f
the hall,
w here
he w
as p u t
into an
isolation room
in the
burn unit.
N ick
w as
treated for
4 days
for C
. dJici1c’
and after
about 2
and a
h alf
days his
sym ptom
s w
ere beginning
to show
signs o f
im p ro
v e
m ent.
M eanw
hile, he
had a
consult for
blood in
the urine
and a
few o th
er things.
I tru
sted the
practitioners. I
felt th
at everybody
cared. H
ow ever,
I w
as concerned
about the
fact th
at his
overall breathing
w as
declining rather
than im
proving and
th at
lie w
as g ettin
g w
eaker. H
e w
as still
not sleeping,
and he
w as
not being
given any
food.
T he
eig h th
day after
surgery, N
ick died
in the
m iddle
o f
the night.
A t
the tim
e he
died he
had not
eaten for
8 days.
H e
had slept
p e r
haps 5
good solid
hours in
the last
6 days
o f
his life.
N evertheless,
his w
as not
an expected
death. ‘The
staffers caring
for him
w ere
devastated.
N ick
and I
w ere
20 years
apart in
age and
had taken
every advantage
o f
35 fabulous
years together.‘T
hrough all
those 35
years, because
o f
our age
difference, w
e had
talked about
the p
o ssih
iIi o f
m y
SECTION III:Practlce4as.d
Learning and
im provem
ent 4
CASE 9: A
Cascade ofSmallEvents:Learnlnq from
an Unexpected
PostsurqlcaiDeath
outliving him
. SC
) w
hen I
learned th
at he
had died,
I w
as not
as shocked
as I
m ig
h t
have been,
h u t
the tim
in g
w as
n o t
w hat
w e
had expected.
in th
at m
o m
en t
I k
it the
axis o f
the earth
shift ever
S O
slightly, and
I knew
n o
th in
g in
m y
life w
as going
to he
the sam
e after
that.
I arrived
at the
hospital at
6:00 a.m
., just
before the
sh ift
change. T
he n ig
h t
nurse w
hom I
had know
n fro
m the
previous n ig
h t
shift w
as w
aiting for
m e
outdoors, guessing
correctly w
here I
m ig
h t
try to
enter so
early in
the day.
S he
gave m
e a
huge em
brace and
cried, w
hispering to
m e
th at
N ick
did n o t
suffrr. T
hen w
e w
en t
upstairs w
here I
w as
allow ed
to stay
w ith
N ick’s
corpse as
long as
I w
anted. W
ith in
a few
m inutes
thc day
shift cam
e on.
B y
the tim
e they
w alked
into the
reception area,
the tw
o nurses
w ere
com pletely
overw helm
ed w
ith sobs.
I em
braced th
em and
p atted
th em
on the
back and
assured them
th at
N ick
had had
a w
onderful life
and had
achieved 11w
m ore
than he
ever th
o u
g h
t he
m ight.
lie had
no dream
s unsatisfied.
A fter
1 had
held b o th
nurses 11w
a w
hile, I
sort o f
felt a
soap box
rising u n d er
m y
feet, and
I talked
to the
assem bled
nursing staff
about how
it w
as okay
for m
e because
I u n d ersto
o d
d eath
w as
a p art
o f
life. I
told them
how gratefhl
w e
b o th
had been
11w the
b rillian
t care
w e
had had
and th
at N
ick had
been so
appreciative 11w
th eir
taking such
good care
o f
him and
being so
concerned for
his w
ell— being.
I sp
en t
an o th
er 4
hours or
so w
ith N
ick’s body,
and th
at w
as an
im p
o rtan
t th
in g
flr m
e. I
alw ays
th o
u g
h t
so m
eth in
g like
th at
w ould
he disturbing,
h u t
it w
as good
to he
w ith
the body
th at
I knew
so w
ell, and
to learn
so phunly
th at
the person
I loved
had already
left.
T he
g astro
en tero
lo g ist
cam e
to offer
his condolences
w hile
I w
as still
in the
room w
ith N
ick. I
had expressed
som e
concern earlier
ab o u t
su b stan
d ard
clean in
g and
ab o u t
erroneous in
stru ctio
n s
I had
been given.
F or
exam ple,
1 had
been told
to w
ear a
m ask
as p art
o f
co n tact
b u t
I learned
on the
in tern
et th
at C
di/Jieuic p recau
tio n s
d o n t
consider tran
sm issio
n by
air. Ihe
specialist said
m y
o b serv
atio n s
w ere
leg itim
ate and
th at
I shouldn’t
th in
k th
at because
I w
as n o t
a m
edical person
th at
w h
at I
said w
as irrelevant.
T he
o th
er th
in g
I told
him w
as th
at I
really w
an ted
to m
ake a
difference. I
w an
ted to
salvage so
m eth
in g
g o rd
out o f
this u n e x
pected d eath
th at
m ig
h t
help an
o th
er p atien
t, and
N ick
w ould
w an
t th
at, tO
C ).
‘The physician
told inc
he w
ould help
m e
if I
w anted
to pursue
this. Iw
as very
grateful 11w
th at
encouragem ent.W
ith in
a w
eek I
returned to
the hospital’s
acute care
w ard
w here
N ick
had first
been after
surgery O
n e
o f
the nurses
w ho
had cared
for him
in his
first few
days recognized
m e.
S he
expressed her
c()ndC )letces’
‘and said
this w
as quite
tragic. I
asked her
how she
had found
out th
at N
ick had
died. S
he said
she fbund
out about
his death
in the
nurses’ coifte
room .
I th
o u g h t,
“M an,
this is
terrible.” lhese
nurses w
ere shocked
about w
hat had
happened tC
) a
p atien
t w
ho w
as in
th eir
care, hut
they had
no w
ay o f
know ing
about it
except throt.zgh
hospital gossip.
A n aly
zin g
the C
auses A
few w
eeks later
I requested
N ick’s
chart. I
w an
ted to
know w
hat had
happened and
how to
in terp
ret the
autopsy report
I knew
w as
com ing.
h u t
I had
no m
edical know
ledge, so
I talked
to N
ick’s and
m y
form er
fam ily
physician, w
ho had
retired but
w as
still living
in our
com m
unity. W
e also
had a
couple o f
nurse friends
w ho
w ere
anxious to
learn how
th eir
friend N
ick had
died and
w ere
w illing
to help
m e
decipher the
chart. So
I m
et w
ith each
o f
them .
I w
as absolutely
taken aback
w hen
one o f
the nurses
said the
signs w
ere all
there th
at N
ick w
as g
ettin g
ready to
crash. S
he said,
“A t
this p o in
t in
m y
hospital, N
ick w
ould have
been in
the intensive
care unit.
11w m
ore I
learned about
w hat
N ick’s
m edical
experience actually
had been,
the m
ore I
realized th
at these
preventable “com
plications
SECTION II:
PracticeB ased
Learning and
Im provem
ent CASE
9: A
C ascade
of Sm
all Events:
Learning from
an U
nexpected Postsurgical
D eath
in care
happen every
day.T he
fact th
at he
died m
ig h t
have been
an unusually
d ram
atic outcom
e, b u t
postoperative delirium
w as
p re
dictable thr
a 79-year-old
m ale
w ith
the typical
com orhidities
th at
he had.
W e
w ere
never aw
are th
at postoperative
delirium could
be lethal.
I th
o u
g h
t about
his d eterio
ratin g
respiration, his
im m
o b ility
in bed,
his starvation,
his hallucinations
th at
prevented sleep.
I’m no
m edical
person, h u t
it seem
ed to
m e
th at
m obility, breathing,
eating, and
sleeping are
p retty
fundam ental
to h ealth
and recovery.
‘T hese
factors w
ere not
consistently tracked
in m
y husband’s
chart.
I felt
th at
the care
plan for
N ick
w as
frag m
en ted
, narrow
ly m
a tc
h ing
sym ptom
s to
specialties, vet
m issing
the co
n tin
u o u s
arc o f
experience o f
the p atien
t. P
atien t
safety researchers
often use
Jam es
R eason’s
“S w
iss cheese
m odel
to refer
to the
causes o f
m edical
harm ,
arguing th
at active
and laten
t causes
m ust
line up,
like holes
in slices
o f
S w
iss cheese,
to create
the circum
stances for
an u
n e x
pected outcom
e. B
u t
it seem
ed to
m e
th at
in N
ick’s case
each slice
w as
w ay
m ore
hole than
cheese and
th at
the o
p p
o rtu
n ity
ftr disaster
w as
far g reater
th an
it should
have been.
O n e
th in
g th
at N
ick often
said to
m e
w as
th at
catastrophes in
av ia
tion happen
as a
cascade o f
sm all
events. ‘The
danger is
th at
once the
cascade starts,
there is
n o th
in g
you can
do to
halt it.
Y ou
can’t th
in k
quickly enough
to begin
to roll
it hack.
I th
in k
th at
is precisely
w hat
happened w
ith N
ick. H
e experienced
a n u m
b er
o f
dangerous conditions
th at
w ere
all associated
w ith
each other,
co m
p o u n d ed
each other,
and eventually
becam e
a cascade
th at
w as
very difficult
to stop.
B y
the tim
e the
danger to
the p atien
t w
as recognized,
there w
asn’t enough
tim e
to figure
out exactly
w h at
w as
h ap
p en
in g
and w
hat should
he done
to rescue
N :ick.
T he
autopsy cam
e hack
and to
nw surprise
he had
bled to
death. H
e had
experienced a
m assive
G I
(gastrointestinal) hem
orrhage. T
here w
ere m
icrolesions in
his d u o d en
u m
th at
had filled
his sm
all intestine
and colon
w ith
freshly clotted
blood. H
is h eart
had stopped
due to
inadequate blood
supply.
P u sh
in g
E v ery
S tep
o fthe
W ay
A sto
n ish
ed at
hearing n
o th
in g
m ore
from the
system ,
I conducted
m y
ow n
version of
a root
cause analysis.
I w
anted to
help the
system learn
w hile
I healed,
so I
needed to
build p artn
ersh ip
s w
ith the
practitioners. B
ut I
had to
push every
step o f
the w
ay.
I decided
th at
I needed
to interview
his caregivers.
I did
this not
so m
uch to
find out
w hy
N ick
died as
to find
out m
ore about
w hy
the system
did not
w ork
w ell.It
w as
certainly not
w orking
w ell
for these
people w
ho w
ere S
O affected
by N
ick’s death
but w
ere given
so little
in fb
rm atio
n .
A nd
if a
p atien
t dies
unexpectedly and
there are
care quality
questions com
ing out
o f
the chart,
I th
o u
g h
t I
needed to
do som
ething to
fix this
gap.
I m
ade ap
p o in
tm en
ts w
ith each
o f
his clinicians.
I asked
th em
really general
questions like,
“W h at
is w
rong in
healtheare?” “W
hat’s w
rong in
the system
you w
ork in?”
“W h
o m
akes the
decisions?” “W
h at
m akes
them m
ake a
decision on
that?” and
“H ow
can I
in flu
ence th
eir decision
m aking?”
I w
as struck
by their
organizational naiveté.
It seem
ed to
m e
th at
healthcare w
orkers w
ere not
very strategically
astute, in
the sense
o f
u n
d erstan
d in
g how
pow er
is used
and d istrib
u ted
in their
system .
A problem
arose w
hen I
interview ed
the surgeon.
I asked
him about
N ick’s
discharge sum
m ary
w hich
w as
onl.y a
paragraph long. Ih
e first
few sentences
o f
the sum
m ary
explained the
surgery and
did so
accu raw
ly and
concisely B
ut the
second half;
about the
postoperative ex
p e
rience, w
as flaIl
o f
errors, om
issions, and
m isleading
assessm ents
o f
N ick’s
care. T
he stated
cause o f
death w
as w
rong, w
ith no
m ention
o f
the G
I bleed.
It said
N ick
died o f
cardiorespiratory failure
and in
d i
cated that
I had
declined an
autopsy In
fact I
had im
m ediately
signed the
release for
the autopsy
that w
as then
ordered and
perform ed.
T he
surgeon w
as also
the head
o f
quality im
p ro
v em
en t
for surgery.
G ently,
w ith
o u t
trying to
be aggressive,
I asked
him if
he could
SECTION III:Practice-B
ased Learninç
and Im
provem ent
CASE 9:A
Cascade ofSm
all Events:
Learning from
an U
nexpected PoitsurgicalD
eath
correct the
discharge in
fo rm
atio n ,
because I
w an
ted N
ick’s ch
art to
he correct
in case
it should
ever be
screened for
a retrospective
study or
research. I
w an
ted N
ick’s w
ay o f
dying to
have a
chance o f
b eco
m in
g accurate
“data” for
learning. T
he surgeon
told m
e, “I
do n o t
take directions
from fam
ily m
em bers.”
I w
as astounded.
I asked
h im
if N
ick’s case
had been
review ed
by anyone
hut him
. H
e said,
IN C
).
C learly,
in the
surgeon’s eyes,
N ick’s
death did
not result
from su
rg i
cal error
and therefore
did not
concern him
or contain
lessons for
him or
his colleagues,
ib is
surgeon w
as N
ick’s “m
ost responsible
physician,” b
u t
he had
not taken
real stew
ardship o f
N ick’s
p o sto
p erative
experience.T he
silos o f
specialties got
in the
w ay
o fe
o m
p re
hensive care
and no
one w
as really
responsible for
the p atien
t.
T w
o years
later, I
presented N
ick’s case
as part
o f
a conference
on m
edical ethics
and disclosure
o f
u n an
ticip ated
m edical
outcom es.
T he
hospital’s ch
ief executive
officer w
as in
the audience.
S om
e people
in the
room w
ere resistant
to m
y narrative
and analysis,
hut others
saw value
in it
and w
ere very
w elcom
ing. I
gave m
y 20—
m inute
talk and
I could
feel the
tension in
the room
. lle
C E
O attem
p ted
to apologize
and I
kind o f
cut him
off. I
told him
there had
never been
a review
o f
this case
and to
m y
best u n d erstan
d in
g an
effective apology
can only
take place
if you
know w
h at
you are
apologizing fir.
I-Ic quickly
agreed. H
e invited
m e
back a
few w
eeks later
and offered
b o th
a w
ritten and
an oral
apologv
A t
th at
point, I
very m
uch u n d ersto
o d
th at
this w
hole th
in g
w as
a hit
o f
a dance.
It w
as a
ritual th
at w
as necessary
as m
uch for
the h ealth
au th
o rity
as it
w as
for m
e. I
had accounted
for nw
experience, and
now the
health au
th o rity
had to
account for
its experience.
I th
in k
w e
succeeded in
reaching an
u n d erstan
d in
g ,but
only partially.
T he
u n d erstan
d in
g w
ith in
the health
au th
o rity
about N
ick’s death
is still
w oeftilly
incom plete.
T he
apology w
as also,
therefore, quite
incom plete.
T he
practitioners w
ho w
ere involved
have never
m et
to
review the
case and
so still
have lim
ited appreciation
o f w
h at
N ick’s
jo u rn
ey w
as to
d eath
and w
hat their
role m
ay have
been in
it. L
e a rn
ing from
this tragedy
never occurred.
C onclusion
S ince
N ick’s
death, I
have co
m m
itted m
yself to
fu ll-tim
e p
a tie
n t
advocacy. I
th in
k th
at the
challenges in
healthcare quality
have everything
to do
w ith
creating an
o p p o
rtu n ity
for patients
and practitioners
to reconnect.
C h an
g e
happens collahoratively.
It h
a p
pens w
ith shared
understanding. I
th in
k th
at at
its core,
health care
is all
about relationships
and trust.
N ick
and I
had com
plete o p
ti m
istic ftiith
in the
quality o
f the
health care
th at
w as
ahead o f
us. B
etrayal o f
th at
tru st
has been
m y
largest w
ound. T
his is
w hat
I struggle
to recover
from .
W e
trusted and
respected, and
it w
a s
n o
t
returned.
T he
core o f
the problem
is th
at healthcare
providers are
not able
to see
the p
atien t
as a
w hole.
I th
in k
th at
if today
w e
gathered N
ick’s 8
or 10
m ain
healthcare providers
into a
room —
the lead
nurses, the
specialists, and
the surgeon—
they w
ould have
a difficult
tim e
recall ing
the case.T
hey m
ig h t
rem em
ber m
e and
N ick,
h u t
they w
ouldn’t he
able to
reconstruct the
care experience
because it
w as
so fra
g m
ented. I
saw the
case, I
review ed
the case,
hut nobody
else saw
it
as a
continuous joined—
up p atien
t experience
o f
care.T o
them ,
there w
as a
single discrete
event: an
unexpected, u n fo
rtu n ate
d eath
in the
hospital. T
hey didn’t
see anything
to review
.
W e
talk o f
w an
tin g
p atien
t-cen tered
care and
o f
good p atien
t o u
t com
es as
a m
easure o f
success. B
ut only’
the p atien
t can
tell you
if the
outcom e
is good.
O nly’
the p
atien t
can tell
you w
hat m
atters and
if the
expectation w
as m
et. F
or change
in health
care to
succeed, w
e need
to plug
in p
atien t
voices from
boardroom to
bedside; w
e need
to em
pow er
patients in
the care
plan itself
If health
care is
about patients,
then patients
have to
be involved
in the
design and
the
SECTION III:Practice-B
ased leam
in9 aad
Im provem
ent CASE
9:A Cascade
ofSm allEvents:team
ing from
an U
nexpected PostsargicalD
eath
delivery and
the governance
o f
health care
(C anfield,2013).
C o n
necting the
patient to
the healthcare
treatm ent
and delivery
ex p
eri ence
is huge
for m
e. I
doW t
have all
the answ
ers, but
I know
that, collectively,the
patients have
the answ
ers. P
atients are
the experts
in the
patient experience.
C ase
D iscussion
C arolyn
C anfield
raises several
issues in
her discussion
o f
her h u s
band’s case.T
he first
is w
hat she
sees as
the extrem
e fragm
entation o
fthe healthcare
system , preventing
healthcare providers
from see
ing their
patients as
com plete
persons and
from understanding
their care
as a
w hole.
O ne
consequence she
sees is
that the
inability to
follow a
patient’s case
in its
entirety can
preventhealthcare providers
from seeing
the consequences
o f
their contribution
to care,
and therefore
prevent them
from recognizing
and preventing
the causes
o f
harm .
A s
an exam
ple o
f this,
she cites
the lack
o f
system atic
charting o
f variables
that she
considers to
have been
significant contributors
to her
husband’s decline:
m alnutrition,
lack o
f sleep,
lack o
f m
obilityç and
delirium .
A nother
issue that
C arolyn
C anfield
raises is
patient-centered care.
S he
says,“P atients
have the
answ ers.”
B y
this she
m eans
that the
patient voice
needs to
be m
uch stronger
in health
care in
order to
provide the
guidance that
healthcare professionals
need to
be sure
they are
providing the
correct treatm
ent to
achieve the
outcom e
desired by
each p atien
t
M s.C
anfield believes
thatthe design
ofthe healthcare
system in
ev i
tably leads
to practitioner
burnout.S he
believes that
the frag
m en
ta tion
o f
the healthcare
system im
pedes a
sense o
f m
eaning in
w ork
by preventing
practitioners from
seeing the
outcom es
o f their
in ter
actions w
ith patients,
their role
in helping
and healing
in the
lives of
patients and
fitm ilies.
Finally,C arolyn
C anfield
says that
this m
atters because
health care
is all
about relationships.
S he
feels that
trust is
betrayed w
hen high-quality
care is
expected but
not provided,w
hen patient
w ell
being is
treated as
subordinate to
m edical
specialtyç w
hen no
one takes
responsibility for
patient outcom
e, and
w hen
unexpected adverse
outcom es
are not
valued as
opportunities for
im provem
ent (C
anfield, 2012).
Q uestions
1. W
here do
you think
the system
failed N
ick Francis?
2. H
ave you
w itnessed
fragm entation
in the
healthcare system
? H
ow do
you think
it m
ight prevent
a patient
from receiving
optim al
care? W
h at
do you
think could
be done
to prevent
fragm entation
and the
problem s
th at
m ight
arise from
it?
3. H
ow can
w e
learn to
recognize and
correct care
failures from
fragm entation,
as distinct
from m
edical error?
4. D
o you
agree that
the lack
o f
patient voice
is an
issue in
health care?
R esearch
the w
ays that
patients are
becom ing
involved in
the design,governance,
and delivery
o f
health care.W
hich w
ays do
you see
as m
ost effective?
5. W
h at
problem s
do you
see w
ith our
current m
ethod o
f charting,and
w hat
do you
think the
individual healthcare
practitioner can
do about
it?
6. D
o you
feel that
m ore
coherence in
patient treatm
ent w
ould im
prove w
orkplace satisfaction?
7. D
o you
agree that
health care
is about
relationships? W
h at
sorts o
f actions
do you
think can
erode trust
betw een
patient and
provider,and how
can these
be avoided?
W h at
behaviors build
trust in
healthcare relationships?
8. W
hich o
f the
core com
petencies for
the health
prokssions are
m ost
relevant fbr
this case?
W hy?
